Navigating the tricky landscape of medical appointments for yourself and your family is no small feat. You may even breathe a sigh of relief when everyone’s checkups are complete. Then, months later, an unexpected bill or letter arrives. All or part of your insurance claims has been denied. There may be an out-of-pocket cost for services you thought were covered. The data shows it is more likely to happen to us. A study published by JAMA Network Open reported that racial minorities (Blacks, Hispanics, and Asians) and lower-income patients were twice as likely to have their claims denied than their non-Hispanic white counterparts. Another study showed we received higher bills.
So, don’t ignore the bill or panic. Instead, follow our suggestions, which are geared toward those with private insurance or Medicare.
Study The Details
Before effectively advocating for yourself, you must learn what you’re advocating against. If you receive a verbal denial, write down everything the representative says. Get their employee identification information. Ask that all information be sent in writing. If they refuse, ask to speak with a supervisor.
Ensure you begin the call by obtaining a reference number if you “accidentally” get disconnected when you try to escalate the call. When you receive the written denial, scan it to have an electronic copy.
Ask for additional information as well—request access to the determining criteria from which the decision was made. If you are denied access to that list, document that.
1. File An Internal Appeal
Many people do not bother to push back against denials. You can file an appeal when your insurance provider denies you. If the company suddenly drops you from coverage, this also applies. There is an internal appeal process where you can formally request that another person examine your rejection and rule on it. Familiarize yourself with the process at your company. This could possibly include several rounds of investigations. Keep any notes and recommendations from your healthcare provider readily available—place paper documents in a folder that you can access quickly. Add electronic files in a folder on your desktop or cloud drive clearly labeled “APPEAL” or something easily recognizable.
Be prepared. If you’re not ready, processes can be stalled. The National Association of Insurance Commissioners has a PDF with sample letters available for download here.
2. Request An External Appeal
If your internal appeal is unsuccessful, keep going. You can file an external appeal. In this process, a third party reviews your case and recommends whether or not the insurance provider’s initial ruling should stand or be reversed. Documentation is just as helpful during this process as during an internal appeal, so hold on to anything you submitted during the original appeal process.
3. Understand Medicare Has its Own Appeals Process.
When Medicare denies your claim for any reason, it is required to issue a Notice of Denial of Medical Coverage or Payment. Go to their site to download the Integrated Notice Instructions and Integrated Download Forms for information to help you file an appeal. You can also submit questions regarding these specific forms to https://appeals.lmi.org.
Then, File an Appeal.
Whether your coverage is for Original Medicare, Medicare Advantage, or another Medicare health or drug plan, you can request free Medicare counseling from your State Health Insurance Assistance Program or get their local number here. Sometimes, such as hospitalization, you can ask for a fast appeal.
The Appeal process in a Medicare drug plan may have up to five steps.
- Redetermination of your plan
- Reconsideration from an Independent Review Entity (IRE)
- Decision by the Office of Medicare Hearings and Appeals (OMHA)
- Review by the Medicare Appeals Council
- Judicial Review in Federal District Court
For example, you can contact the non-profit medicarerights.org for their Part D Appeals Resources if you have received a Medicare D denial. They include step-by-step tips on dealing with the helpline and sample letters for Medicare and Providers.
4. Explore Additional Resources
Sometimes, you may have to tap into organizations like Voters for Cures, who help patients like you advocate for necessary medication and treatments and help you interact with your representatives.
The bottom line is that when your insurance company denies you access to necessary medications and treatments, don’t take no for an answer. Work with your HCP, advocacy groups, and other resources to fight for what you need.
